Provider Demographics
NPI:1487174348
Name:BISHOP, AMANDA LYN (OTR)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:LYN
Last Name:BISHOP
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:LYN
Other - Last Name:BISHOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:817 N 56TH AVE W
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55807-1328
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4000 LONDON RD
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55804-2220
Practice Address - Country:US
Practice Address - Phone:218-428-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNNAOtherNA